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3153 CNS - nat > ic12 depression > Flashcards

ic12 depression Flashcards

1
Q

Diagnostic criteria of Depression

A

At least 5 symptoms for 2 weeks and change from previous functioning + Must have either Depressed mood or Loss of interest

In SAD CAGES
Interest (Anhedonia)
Sleep: Insomnia
Appetite: poor, leading to weight loss

Depressed mood / Irritable mood in children

Concentration, decision making
Activity: psychomotor retardation
Guilt: worthlessness
Energy: low
Suicidal thoughts

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2
Q

What should be ruled out for diagnosis of Depression? (2 points)

A

1) Bipolar disorder, as antidepressants can cause mania

2) Check labs eg. blood glucose, FBC, LFT, TFT to rule out other conditions causing depressive symptoms
Eg. Delirium, psychosis, thyroid dysfunction, diabetes

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3
Q

What are 2 rating scales to assess progress / severity of depression?

Which scale proves remission, which scale proves need to treat?

A

1) Hamilton Rating Scale for Depression (HAM-D)
Gold standard
Clinician rated
Remission: HAM-D score 7 or below

2) Patient Health Questionnaire (PHQ-9)
Patient self rated
Score ≥ 10 means moderate, Need antidepressant treatment

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4
Q

Non pharm treatment for depression

Should herbal medication be used for depression?

A

1) Sleep hygiene
2) Psychotherapy, should be adjunct to meds
3) ECT (Electronic convulsive therapy)

St John’s Wort
Can cause alot of DDI eg. serotonin syndrome
Do not use together with antidepressants

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5
Q

What is considered physical symptoms of depression?

How long does it take to resolve?

A

Sleep, appetite

1-2 weeks

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6
Q

How long do mood symptoms take to improve?

Why?

A

at least 6 weeks

Due to gradual downregulation of autoreceptors

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7
Q

What are 3 different drug targets for antidepressants?

A

1) Specific reuptake transporter
Blocks reuptake transporter, so signal can be sustained
Eg. SSRI, SNRI, TCA, Bupropion

2) MAO
MAO breaks down neurotransmitters
Eg. Moclobamide

3) Pre-synaptic autoreceptors
Signals to synapse to reduce release of neurotransmitters
(-) feedback mechanism
Will downregulate after a few weeks of sustained high neurotransmitters
Eg. Mirtazapine (autoreceptor antagonist)

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8
Q

When are antidepressants indicated?

A

For moderate severity onwards: PHQ-9 score = 10 onwards

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9
Q

What should be recommended for low energy?

A

Choose something that increase NE, DA

Bupropion or SSRI (Fluoxetine, Escitalopram)

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10
Q

What should be used for patients with sexual disorders from antidepressants

A

Mirtazapine
Bupropion

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11
Q

What is recommended for pts unable to sleep

A

Mirtazapine

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12
Q

What are the first line medications for depression (4 points)

A

SSRI
SNRI
Mirtazapine
Bupropion

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13
Q

Which antidepressants have the least DDI?

A

Mirtazapine, Escitalopram, Venlafaxine/Desvenlafaxine (SNRI)

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14
Q

What is the MOA of Mirtazapine

A

NaSSA = Noradrenergic and Specific Serotoninergic Antidepressant

MOA
Antagonise 5HT2, 5HT3 → so that serotonin will bind to 5HT1A receptors
Antagonise A2 autoreceptor → Increase NE

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15
Q

Side effects of Mirtazapine?

Hence when is Mirtazapine indicated?

A

Sedation (H1 antagonism)
Weight gain (5HT3 antagonism)
No sexual side effects (due to 5HT2 antagonism)

For patients with
1) Has sexual side effects from serotonergic drugs (SSRI, TCA)
2) Poor appetite
3) Cannot sleep

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16
Q

What are SSRIs? (6 points)

They are generally… (3 points)

A

Selective Serotonin Reuptake Inhibitors

Fluoxetine
Paroxetine
Fluvoxamine
Escitalopram
Citalopram
Sertraline

Generally not sedating, no anticholinergic SE, no orthostatic hypotension

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17
Q

Which is the most problematic SSRI?

A

Paroxetine: most anticholinergic, sedating, weight gain, shortest half life (causing withdrawal symptoms), 2D6i

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18
Q

Side effect of Escitalopram / Citalopram

A

QTc prolongation at high dose in elderly

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19
Q

Which SSRI will cause QTc prolongation in elderly at high doses

A

Escitalopram, Citalopram

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20
Q

What drug should be given with food to increase bioavailability

A

Sertraline

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21
Q

SSRI with the most DDI

A

Fluvoxamine (1A2i and 2C19i)

22
Q

Sertraline should be…

A

give with food to increase oral bioavailability

23
Q

Characteristics of Fluoxetine (2 points)

A

2D6i, long half life

24
Q

Side effects of SSRI (4 points)

A

GI side effects

Sexual side effects

Hyponatremia in elderly (SIADH)
Cause drowsiness, confusion, convulsions

increase risk of bleeding in elderly

25
Q

What are SNRI

Example of SNRI

A

Selective Serotonin and Norepinephrine Reuptake Inhibitors

Duloxetine
Venlafaxine

26
Q

Which antidepressant can be used for peripheral neuropathy?

A

SNRI, cos similar structure to tramadol

27
Q

Side effects of SNRI

A

Increase BP (due to increased Norepinephrine)

28
Q

MOA of Bupropion

A

Block reuptake of Norepinephrine and Dopamine

29
Q

When should Bupropion be given? Why?

A

Should be given in the morning, as it is very stimulating

30
Q

Side effects of Bupropion (3 points)

A

SIP

Seizures
Insomnia
Psychosis

Does not help with eating disorder

31
Q

Which patients are contraindicated in Bupropion (4 points)

A

History of seizures,
Patients with psychosis
patients with insomnia
patients with eating disorders

32
Q

What CYP does Bupropion inhibit

A

2D6 inhibitor (same as Fluoxetine, Paroxetine)

33
Q

3 examples of TCA

A

Amitriptyline
Clomipramine
Imipramine

34
Q

MOA of TCA

A

Block reuptake of Norepinephrine, Serotonin
Essentially an SNRI

35
Q

Why are TCA not first line?

A

Many SE eg. GI, sexual, anticholinergic, sedation, orthostatic hypotension (antagonise a1 adrenoreceptors), conductance abnormalities (if overdose 1 week supply and taken with alcohol)

36
Q

What causes improvement in antidepressant mood

What causes sexual and GI side effects?

How to overcome these side effects?

A

Serotonin binding to 5HT1 receptors, hence blocking all other receptors will increase 5HT1 binding

Sexual: Agonism of 5HT2 receptors (cos 2 ppl..)
Occurs in SSRI, TCA

GI: Agonism of 5HT3 (cos 3 parts of colon)
Occurs in SSRI, TCA

Change to Mirtazapine (blocks both 5HT2 and 5HT3 receptors)

37
Q

Which antidepressants have the longest half lives (2 points)

A

Fluoxetine
Vortioxetine (a SMS)

38
Q

What can be used as adjunct to antidepressants if partial treatment

A

For depression, adjunct to antidepressants
SGA eg. Aripiprazole, Brexpiprazole, Quetiapine XR

Sleep only:
Benzodiazepines
Z-hypnotics
1st gen Antihistamines

39
Q

Example of MAOi

What should be observed when switching to or from MAOi

A

Moclobemide

Washout needed
1 day if stopping Moclobemide → another drug
1 week if stopping another drug → Moclobemide

40
Q

What causes hyponatremia?

A

SSRI, caused by SIADH

41
Q

Most impt counselling point in young adults

A

younger patients ≤ 24 years old, higher risk of suicide

42
Q

What drugs can cause serotonin syndrome? (7 points)

A

Triptans
Sibutramine
Opioids
Linezolid
Ritonavir
MAOi
SSRI, SNRI, TCA

43
Q

Drug food interaction with antidepressants

A

Space apart with alcohol for 4-6 hours

44
Q

What happens if suddenly stop taking antidepressant?

Associated with which Antidepressant?

How to manage?

A

Antidepressant Discontinuation Syndrome
Symptoms: Flu-like symptoms, Insomnia, tingling sensation, anxiety

Paroxetine (SSRI), Venlafaxine (SNRI)

Not life threatening, discomfort to patients
Resolves 1-2 weeks without treatment
Gradually tapering dose by half tablet every 1-2 weeks

Not necessary if drug has long half life or active metabolites eg. Fluoxetine, Vortioxetine (SMS), Bupropion

45
Q

Counselling points for antidepressants (4 points)

A

1) Drug will take a few weeks to work

2) Do not take at the same time as alcohol, space 4-6hrs apart

3) If condition is worsening or feel suicidal (esp for ≤ 24 years old), go to the doctor

4) Possible side effects eg. drowsiness, insomnia, orthostatic hypotension, sexual dysfunction

46
Q

Which antidepressants have short half lives?

A

Paroxetine, Venlafaxine (hence will have antidepressant discontinuation syndrome)

47
Q

What is the course of antidepressant therapy?

When to consider changing medication?

A

At least 6 months

change if ineffective after 2-4 weeks

48
Q

What are the 2D6 inhibitors

A

Fluoxetine
Paroxetine
Bupropion

49
Q

What if a patient is poor metaboliser of 2D6? Which SSRI to give?

A

Escitalopram, Sertraline

50
Q

What if patient is poor metaboliser of 2C19? Which SSRI to give?

A

(FFP)
Fluoxetine, Fluvoxamine, Paroxetine

51
Q

Which first line is safe to give for poor metaboliser of 2C19 or 2D6?

A

Bupropion, Mirtazapine

but note that Bupropion is inhibitor of 2D6

3153 CNS - nat (11 decks)

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